|
TRIATHLON X3 TIB INSRT #8 19MM
|
Facility
|
OP
|
$8,968.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,165.90 |
| Max. Negotiated Rate |
$8,609.76 |
| Rate for Payer: Aetna Commercial |
$6,905.74
|
| Rate for Payer: Anthem Medicaid |
$3,084.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,995.43
|
| Rate for Payer: Cash Price |
$4,484.25
|
| Rate for Payer: Cigna Commercial |
$7,443.86
|
| Rate for Payer: First Health Commercial |
$8,520.08
|
| Rate for Payer: Humana Commercial |
$7,623.22
|
| Rate for Payer: Humana KY Medicaid |
$3,084.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3,115.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,354.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,618.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,690.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,146.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,892.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,726.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,793.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,165.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,780.24
|
| Rate for Payer: PHCS Commercial |
$8,609.76
|
| Rate for Payer: United Healthcare All Payer |
$7,892.28
|
|
|
TRIATHLON X3 TIB INSRT #8 22MM
|
Facility
|
IP
|
$8,968.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,165.90 |
| Max. Negotiated Rate |
$8,609.76 |
| Rate for Payer: Aetna Commercial |
$6,905.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,995.43
|
| Rate for Payer: Cash Price |
$4,484.25
|
| Rate for Payer: Cigna Commercial |
$7,443.86
|
| Rate for Payer: First Health Commercial |
$8,520.08
|
| Rate for Payer: Humana Commercial |
$7,623.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,354.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,618.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,690.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,892.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,726.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,793.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,165.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,780.24
|
| Rate for Payer: PHCS Commercial |
$8,609.76
|
| Rate for Payer: United Healthcare All Payer |
$7,892.28
|
|
|
TRIATHLON X3 TIB INSRT #8 22MM
|
Facility
|
OP
|
$8,968.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,165.90 |
| Max. Negotiated Rate |
$8,609.76 |
| Rate for Payer: Aetna Commercial |
$6,905.74
|
| Rate for Payer: Anthem Medicaid |
$3,084.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,995.43
|
| Rate for Payer: Cash Price |
$4,484.25
|
| Rate for Payer: Cigna Commercial |
$7,443.86
|
| Rate for Payer: First Health Commercial |
$8,520.08
|
| Rate for Payer: Humana Commercial |
$7,623.22
|
| Rate for Payer: Humana KY Medicaid |
$3,084.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3,115.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,354.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,618.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,690.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,146.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,892.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,726.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,793.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,165.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,780.24
|
| Rate for Payer: PHCS Commercial |
$8,609.76
|
| Rate for Payer: United Healthcare All Payer |
$7,892.28
|
|
|
TRIATHLON X3 TIB INSRT #8 25MM
|
Facility
|
IP
|
$8,968.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,165.90 |
| Max. Negotiated Rate |
$8,609.76 |
| Rate for Payer: Aetna Commercial |
$6,905.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,995.43
|
| Rate for Payer: Cash Price |
$4,484.25
|
| Rate for Payer: Cigna Commercial |
$7,443.86
|
| Rate for Payer: First Health Commercial |
$8,520.08
|
| Rate for Payer: Humana Commercial |
$7,623.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,354.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,618.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,690.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,892.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,726.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,793.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,165.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,780.24
|
| Rate for Payer: PHCS Commercial |
$8,609.76
|
| Rate for Payer: United Healthcare All Payer |
$7,892.28
|
|
|
TRIATHLON X3 TIB INSRT #8 25MM
|
Facility
|
OP
|
$8,968.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,165.90 |
| Max. Negotiated Rate |
$8,609.76 |
| Rate for Payer: Aetna Commercial |
$6,905.74
|
| Rate for Payer: Anthem Medicaid |
$3,084.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,995.43
|
| Rate for Payer: Cash Price |
$4,484.25
|
| Rate for Payer: Cigna Commercial |
$7,443.86
|
| Rate for Payer: First Health Commercial |
$8,520.08
|
| Rate for Payer: Humana Commercial |
$7,623.22
|
| Rate for Payer: Humana KY Medicaid |
$3,084.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3,115.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,354.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,618.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,690.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,146.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,892.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,726.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,793.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,165.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,780.24
|
| Rate for Payer: PHCS Commercial |
$8,609.76
|
| Rate for Payer: United Healthcare All Payer |
$7,892.28
|
|
|
TRI BEADED W/PA PATELLA 32MM
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI BEADED W/PA PATELLA 32MM
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI BEADED W/PA PATELLA 35MM
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI BEADED W/PA PATELLA 35MM
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI BEADED W/PA PATELLA 38MM
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI BEADED W/PA PATELLA 38MM
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI BEADED W/PA PATELLA 40MM
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI BEADED W/PA PATELLA 40MM
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
TRI CEMENTED STEM 12MM*100MM
|
Facility
|
IP
|
$8,352.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,085.76 |
| Max. Negotiated Rate |
$8,017.93 |
| Rate for Payer: Aetna Commercial |
$6,431.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,514.57
|
| Rate for Payer: Cash Price |
$4,176.01
|
| Rate for Payer: Cigna Commercial |
$6,932.17
|
| Rate for Payer: First Health Commercial |
$7,934.41
|
| Rate for Payer: Humana Commercial |
$7,099.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,848.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,163.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,505.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,349.77
|
| Rate for Payer: Ohio Health Group HMO |
$6,264.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,670.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,589.12
|
| Rate for Payer: PHCS Commercial |
$8,017.93
|
| Rate for Payer: United Healthcare All Payer |
$7,349.77
|
|
|
TRI CEMENTED STEM 12MM*100MM
|
Facility
|
OP
|
$8,352.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,085.76 |
| Max. Negotiated Rate |
$8,017.93 |
| Rate for Payer: Aetna Commercial |
$6,431.05
|
| Rate for Payer: Anthem Medicaid |
$2,872.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,514.57
|
| Rate for Payer: Cash Price |
$4,176.01
|
| Rate for Payer: Cigna Commercial |
$6,932.17
|
| Rate for Payer: First Health Commercial |
$7,934.41
|
| Rate for Payer: Humana Commercial |
$7,099.21
|
| Rate for Payer: Humana KY Medicaid |
$2,872.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,901.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,848.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,163.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,505.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,929.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,349.77
|
| Rate for Payer: Ohio Health Group HMO |
$6,264.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,670.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,589.12
|
| Rate for Payer: PHCS Commercial |
$8,017.93
|
| Rate for Payer: United Healthcare All Payer |
$7,349.77
|
|
|
TRI CEMENTED STEM 12MM*50MM
|
Facility
|
IP
|
$6,746.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$877.05 |
| Max. Negotiated Rate |
$6,476.70 |
| Rate for Payer: Aetna Commercial |
$5,194.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,262.32
|
| Rate for Payer: Cash Price |
$3,373.28
|
| Rate for Payer: Cigna Commercial |
$5,599.64
|
| Rate for Payer: First Health Commercial |
$6,409.23
|
| Rate for Payer: Humana Commercial |
$5,734.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,532.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,978.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,023.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,936.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,059.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,349.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$877.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.43
|
| Rate for Payer: PHCS Commercial |
$6,476.70
|
| Rate for Payer: United Healthcare All Payer |
$5,936.97
|
|
|
TRI CEMENTED STEM 12MM*50MM
|
Facility
|
OP
|
$6,746.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$877.05 |
| Max. Negotiated Rate |
$6,476.70 |
| Rate for Payer: Aetna Commercial |
$5,194.85
|
| Rate for Payer: Anthem Medicaid |
$2,320.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,262.32
|
| Rate for Payer: Cash Price |
$3,373.28
|
| Rate for Payer: Cigna Commercial |
$5,599.64
|
| Rate for Payer: First Health Commercial |
$6,409.23
|
| Rate for Payer: Humana Commercial |
$5,734.58
|
| Rate for Payer: Humana KY Medicaid |
$2,320.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,343.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,532.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,978.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,023.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,366.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,936.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,059.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,349.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$877.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.43
|
| Rate for Payer: PHCS Commercial |
$6,476.70
|
| Rate for Payer: United Healthcare All Payer |
$5,936.97
|
|
|
TRI CEMENTED STEM 9MM*100MM
|
Facility
|
IP
|
$8,352.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,085.76 |
| Max. Negotiated Rate |
$8,017.93 |
| Rate for Payer: Aetna Commercial |
$6,431.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,514.57
|
| Rate for Payer: Cash Price |
$4,176.01
|
| Rate for Payer: Cigna Commercial |
$6,932.17
|
| Rate for Payer: First Health Commercial |
$7,934.41
|
| Rate for Payer: Humana Commercial |
$7,099.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,848.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,163.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,505.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,349.77
|
| Rate for Payer: Ohio Health Group HMO |
$6,264.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,670.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,589.12
|
| Rate for Payer: PHCS Commercial |
$8,017.93
|
| Rate for Payer: United Healthcare All Payer |
$7,349.77
|
|
|
TRI CEMENTED STEM 9MM*100MM
|
Facility
|
OP
|
$8,352.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,085.76 |
| Max. Negotiated Rate |
$8,017.93 |
| Rate for Payer: Aetna Commercial |
$6,431.05
|
| Rate for Payer: Anthem Medicaid |
$2,872.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,514.57
|
| Rate for Payer: Cash Price |
$4,176.01
|
| Rate for Payer: Cigna Commercial |
$6,932.17
|
| Rate for Payer: First Health Commercial |
$7,934.41
|
| Rate for Payer: Humana Commercial |
$7,099.21
|
| Rate for Payer: Humana KY Medicaid |
$2,872.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,901.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,848.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,163.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,505.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,929.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,349.77
|
| Rate for Payer: Ohio Health Group HMO |
$6,264.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,670.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,589.12
|
| Rate for Payer: PHCS Commercial |
$8,017.93
|
| Rate for Payer: United Healthcare All Payer |
$7,349.77
|
|
|
TRICHROME STAIN
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS 87209
|
| Hospital Charge Code |
30001333
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$114.24 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Anthem Medicaid |
$40.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.98
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$98.77
|
| Rate for Payer: First Health Commercial |
$113.05
|
| Rate for Payer: Humana Commercial |
$101.15
|
| Rate for Payer: Humana KY Medicaid |
$40.92
|
| Rate for Payer: Humana Medicare Advantage |
$17.98
|
| Rate for Payer: Kentucky WC Medicaid |
$41.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.72
|
| Rate for Payer: Ohio Health Group HMO |
$89.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.89
|
| Rate for Payer: PHCS Commercial |
$114.24
|
| Rate for Payer: United Healthcare All Payer |
$104.72
|
|
|
TRICHROME STAIN
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS 87209
|
| Hospital Charge Code |
30001333
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.47 |
| Max. Negotiated Rate |
$114.24 |
| Rate for Payer: Aetna Commercial |
$91.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.56
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: Cigna Commercial |
$98.77
|
| Rate for Payer: First Health Commercial |
$113.05
|
| Rate for Payer: Humana Commercial |
$101.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.72
|
| Rate for Payer: Ohio Health Group HMO |
$89.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.89
|
| Rate for Payer: PHCS Commercial |
$114.24
|
| Rate for Payer: United Healthcare All Payer |
$104.72
|
|
|
TRICOMONAS VAGINALIS PCR
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS 87661
|
| Hospital Charge Code |
30001401
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$265.92 |
| Rate for Payer: Aetna Commercial |
$213.29
|
| Rate for Payer: Anthem Medicaid |
$95.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$222.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$229.91
|
| Rate for Payer: First Health Commercial |
$263.15
|
| Rate for Payer: Humana Commercial |
$235.45
|
| Rate for Payer: Humana KY Medicaid |
$95.26
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$96.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$204.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$243.76
|
| Rate for Payer: Ohio Health Group HMO |
$207.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.87
|
| Rate for Payer: PHCS Commercial |
$265.92
|
| Rate for Payer: United Healthcare All Payer |
$243.76
|
|
|
TRICOMONAS VAGINALIS PCR
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
HCPCS 87661
|
| Hospital Charge Code |
30001401
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$277.00
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$32.09
|
| Rate for Payer: Healthspan PPO |
$35.90
|
| Rate for Payer: Multiplan PHCS |
$166.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$193.90
|
| Rate for Payer: UHCCP Medicaid |
$96.95
|
|
|
TRICOMONAS VAGINALIS PCR
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
HCPCS 87661
|
| Hospital Charge Code |
30001401
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$36.01 |
| Max. Negotiated Rate |
$265.92 |
| Rate for Payer: Aetna Commercial |
$213.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$222.43
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$229.91
|
| Rate for Payer: First Health Commercial |
$263.15
|
| Rate for Payer: Humana Commercial |
$235.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$204.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$243.76
|
| Rate for Payer: Ohio Health Group HMO |
$207.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.87
|
| Rate for Payer: PHCS Commercial |
$265.92
|
| Rate for Payer: United Healthcare All Payer |
$243.76
|
|
|
TRICOR FENOFIBRATE 145 MG TAB
|
Facility
|
OP
|
$4.85
|
|
|
Service Code
|
NDC 378306677
|
| Hospital Charge Code |
25001593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
